Aging Pet Questionnaire

It is our hope to gather as much information prior to your pet’s appointment to best manage their medical needs. As pet’s age they may experience changes to their cognitive function, organ function and musculoskeletal system, but these changes are often subtle and difficult to detect. We hope these questions will provide us with as much information as possible about your pet to help us detect the early signs of age-related diseases. In addition to this questionnaire, we have attached a document with more information about age-related diseases, the importance of early detection, and cost of bloodwork to best prepare you for your upcoming visit for your pet’s senior wellness examination.

Please take a few minutes and answer the following questions and review the documents prior to your pet’s upcoming appointment.

All Yes/No questions are mandatory. If answering yes, please add a comment to provide us with more details.

Enter the code provided in your initial email :

General Health:

Have you noticed more frequent urination?	Yes	No

Have you noticed changes to bowel movements?	Yes	No

Have you noticed changes to appetite?	Yes	No

Have you noticed changes to thirst?	Yes	No

Have you noticed any coughing?	Yes	No

Does your pet vomit on a regular basis?	Yes	No

Have you noticed lethargy or listlessness?	Yes	No

Have you noticed any changes to your pet’s weight?	Yes	No

Have you noticed any changes to their appearance?	Yes	No

Additional General Health Comments

Cognitive Function:

Does your pet ever appear disorientated or lost?	Yes	No

Have you noticed any changes with their social interactions?	Yes	No

Have you noticed any changes to sleep/wake cycles?	Yes	No

Have they experienced any house soiling?	Yes	No

Have you noticed any new anxious behaviours?	Yes	No

Additional Cognitive function Comments

Pain/Mobility:

Please describe your pet’s current physical activity.

Have you noticed any changes in their physical abilities (consider duration of walks, stairs, jumping up on surfaces)?	Yes	No

Have you noticed any changes to their posture or the way they walk (gait)?	Yes	No

Additional Pain/Mobility Comments

Nutrition:

Current diet/Formula:
Amount Feeding:
Treats:
Supplements:
Medications:
Please share any additional information or concerns you have.

Client Name :

Pet Name :

Phone Number:

Date: